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Drug and Alcohol Dependence

Nearly one half of all primary care patients have an alcohol or drug disorder. Each stage of addictive illness can be characterized by types and severity of withdrawal and relapse prevention.

Pharmacotherapy for withdrawal syndromes

Detoxification. Pharmacologic therapies are indicated for use in patients with addictive disorders to prevent life-threatening withdrawal complications such as seizures and delirium tremens.

Alcohol withdrawal. Agents that are commonly recommended include diazepam (Valium), lorazepam (Ativan), chlordiazepoxide (Limbitrol) and clorazepate (Tranxene). Longer-acting preparations such as

Signs and Symptoms of Alcohol and Drug Withdrawal


Peak period





1 to 3 days

5 to 7 days

Elevated blood pressure, pulse and temperature, hyperarousal, agitation, restlessness, cutaneous flushing, tremors, diaphoresis, dilated pupils, ataxia, clouding of consciousness, disorientation

Anxiety, panic, paranoid delusions, illusions, visual and auditory hallucinations

Benzodiazepines and other sedative/hypnotics


2 to 4 days


4 to 7 days


4 to 7 days


7 to 14 days

Increased psychomotor activity, agitation, muscular weakness, tremulousness, hyperpyrexia, diaphoresis, delirium, convulsions, elevated blood pressure, pulse and temperature, tremor

Anxiety, depression, euphoria, incoherent thoughts, hostility, grandiosity, disorientation, tactile, auditory and visual hallucinations, suicidal thoughts

Stimulants (cocaine, amphetamines and derivatives)

1 to 3 days

5 to 7 days

Social withdrawal, psychomotor retardation, hypersomnia, hyperphagia

Depression, anhedonia, suicidal thoughts and behavior, paranoid delusions

Opiates (heroin)

1 to 3 days

5 to 7 days

Drug seeking, mydriasis, piloerection, diaphoresis, rhinorrhea, lacrimation, diarrhea, insomnia, elevated blood pressure and pulse

Intense desire for drugs, muscle cramps, arthralgia, anxiety, nausea, vomiting, malaise


Days to weeks

Days to weeks

Hyperactivity, increased pain threshold, nystagmus, hyperreflexia, hypertension and tachycardia, eyelid retraction (stare), agitation and hyperarousal, dry and erythematous skin, violent and self-destructive behaviors

Anxiety, depression, delusions, auditory and visual hallucinations, memory loss, irritable and angry mood and affect, suicidal thoughts

Benzodiazepines and other sedative/hypnotics. The signs and symptoms of benzodiazepine withdrawal are similar to those for withdrawal from barbiturates. Withdrawal is not usually marked by significant elevations in blood pressure and pulse.

Stimulants ( cocaine, amphetamines and derivatives)

Supportive treatment is indicated in patients who are undergoing withdrawal from

For severe withdrawal symptoms with persistent depression, therapy may be initiated with desipramine (Norpramin), at a

Opiates. Management of withdrawal can be accomplished with clonidine (Catapres) or methadone. Federal regulations do

Phencyclidine and other psychedelic agents. Acute symptoms of withdrawal from psychedelic agents may be diminished or reversed by using haloperidol (Haldol), 5 to 10 mg IM or PO every 3-6h prn. Lorazepam, 1 to 2 mg

Medications for relapse prevention

Disulfiram ( Antabuse)

Disulfiram is an aversive agent. The dosage of is 250 mg per day. Disulfiram inhibits acetaldehyde dehydrogenase. An accumulation of acetaldehyde produces an unpleasant reaction when alcohol is consumed that is similar to a severe

Before using disulfiram, patients must have a blood alcohol level of zero and must be able to comprehend the risks and

Methadone maintenance is a form of pharmacologic management of opiate addiction performed in programs that are in

Naltrexone ( ReVia) is an opioid antagonist which inhibits the effect of opiate agonists. Naltrexone is effective in